Endocrinology Investigation and Management Flashcards
Investigations for hypothyroid disease
Thyroid function tests
Anti-TPO antibody
Hypothyroid management
Start levothyroxine at 25-50 micrograms daily.
Adjust dose every 4 weeks according to response.
Check TSH 2 months after any dose change.
Myxoedema coma management
ABCDE Passively rewarm Cardiac monitoring for arrhythmias Monitor UO, fluid balance, CVP, blood sugar, oxygenation. Broad spectrum antibiotics. Thyroxine and hydrocortisone.
Hyperthyroid investigations
Thyroid function tests
TRAb
Scintigraphy if antibody negative or suspected nodular disease.
Potentially thyroid ultrasound for nodule.
Thyroid storm management
Lugol's iodine Glucocorticoids PTU B-blockers Fluids Monitoring
Hyperthyroid management
- Medication: carbimazole (propylthiouracil in 1st trimester) and beta blockers for symptomatic relief.
- Radioiodine.
- Thyroidectomy.
Thyroid cancer investigations.
Ultrasound guided FNA
Maybe excision biopsy of lymph node
Management for papillary microcarcinoma, minimally invasive follicular carcinoma with capsular invasion only or AMES low risk?
Thyroid lobectomy with isthmusectomy.
Management for thyroid cancer with extra-thyroidal spread, mets, nodal involement or AMES high risk.
Sub-total or total thyroidectomy.
Investigation after sub-total or total thyroidectomy
Whole body iodine scanning.
Thyroid mets management
Thyroid remnant ablation (given radioactive iodine).
Investigations for hypercalcaemia of malignancy
Raised calcium and ALP
X-ray, CT, MRI
Isotope bone scan
Hypercalcaemia acute management
Rehydration with saline
Consider loop diuretics once rehydrated
Bisphosponates
Steroids occasionally used.
Investigation after diagnosis of primary hyperparathyroidism
Setamibi scan
Primary hyperparathyroidism management
Surgery
Cinacalcet (calcium mimetic, useful if unfit for surgery)
Indications for parathyroidectomy
End organ damage (bones, gastric ulcers, renal stones, osteoporosis)
Very high calcium
Under 50
eGFR <60ml/min
Familial hypocalciuric hypercalcaemia management
Nothing, it will not cause any problems
Acute hypocalcaemia management
Emergency: IV calcium gluconate
Calcium gluconate infusion.
Hypoparathyroidism long term management
Calcium supplement
Vit D supplement (alphacalcidol)
Pseudohypoparathyroidism biochemical findings
Low calcium
PTH elevated
Pseudohypoparathyroidism management
Same as primary hypoparathyroidism
Chronic rickets/osteomalacia treatment
Vitamin D3 tablet (calcitriol, alfacalcidol)
Combined calcium and vit D.
Vit D resistant rickets treatment
Phosphate and vit D supplements
Maybe surgery
Adrenal insufficiency investigations
Biochemisty Short synacthen test!!! ACTH levels Renin/aldosterone levels Adrenal autoantibodies Imaging
Primary adrenal insufficiency management
Hydrocortisone as cortisol replacement
Fludrocortisone as aldosterone replacement
Remember sick day rules
Secondary adrenal insufficiency management
Hydrocortisone replacement
fludrocortisone unnecessary
Cushings screening tests
Overnight dexamethasone suppression test
24 hour urinary free cortisol
Late night salivary cortisol
Gold standard cushings test
Low dose dexamethasone suppression test
Repeat to confirm
Primary aldosteronism investigation
Biochemical testing (high sodium, low potassium) Plasma aldosterone renin ratio Saline suppression test (2 litres of saline normally suppresses aldosterone by over 50%) Adrenal CT (adenoma) Sometimes adrenal vein sampling to determine whether adenoma or bilateral adrenal hyperplasia
Management of Conn’s adenoma (primary aldosteronism).
Unilateral laparoscopic adrenalectomy.
Management of bilateral adrenal hyperplasia.
Mineralocorticoid receptor antagonists (spironolactone, eplerenone).
Congenital adrenal hyperplasia investigation.
Basal or stimulated 17-OH progesterone (raised)
Can do genetic mutation analysis
CAH management
Glucocorticoid replacement Mineralocorticoid replacement in some Surgical correction Achieve maximal growth potential Control androgen excess Restore fertility
Phaeochromocytoma investigation
Urine - 24 hours catecholamines/metanephrines
Plasma - catecholamines/metanephrins ideally at time of symptoms
MRI scan
MIBG scan
PET scan
Phaeochromocytoma management
Alpha blocker (phenoxybenzamine), then beta blocker.
Fluid and/or blood replacement
Careful anaesthetic assessment
Laparscopic excision (or de-bulking)
Chemotherapy if malignant (radio-labelled MIBG).
Prolactinoma investigations
Raised serum prolactin
MRI pituitary
Pituitary function tests
Visual fields
Prolactinoma management
Dopamine agonists (cabergoline, bromocriptine)
Acromegaly investigations
IGF-1 (age+sex matched) Glucose tolerance test (measure GH after glucose) MRI pituitary Visual fields Pituitary function testing
Acromegaly management
- Pituitary surgery then retest GTT.
- Somatostatin analogues (lanreotide, octreotide).
- Dopamine agonists (cabergoline)
- GH antagonist (pegvisomant, last line, expensive)
Cushings disease (pituitary disease) specific investigation.
CRH test (stimulation test).
Cushings disease (pituitary disease) management.
- Hypophysectomy
- External radiotherapy if recurs.
- Bilateral adrenalectomy.
Cushings syndrome adrenal cause management.
Adrenalectomy
Cushings syndrome ectopic source management.
- Remove source.
2. Bilateral adrenalectomy.
Cushings medical treatment.
- Metyrapone.
- Ketoconazole (hepatotoxic)
- Pasireotide
Pan hypopituitarism investigations.
Pituitary function tests.
Osteoporosis investigation
DEXA scan looking for bone mineral density.
Who is referred for osteoporosis investigation
Patients over 50 with low trauma fracture
Patients at increased risk of fracture based on risk factors calculated using risk assessment tool
Anyone with a 10 year risk assessment for any OP fracture of at least 10%
Osteoporosis lifestyle management
High intensity strength training Low-impact weight-bearing exercise Avoidance of excess alcohol Avoidance of smoking Fall prevention
Osteoporosis management
Vit D and Ca supplements
Bisphosphonates (alendronate, risedronate)
Zoledronic acid (once yearly IV infusion)
Denosumab (6 monthly SC injection)
Teriparatide
When to treat in osteoporosis
Consider antiresorptive therapy when T-score < -2.5
If ongoing steroid use (3 months or more) or vertebral fracture, then when T score
Paget’s disease management
Bisphosphonates if pain not responding to analgesia.
Osteogenesis imperfecta management
Fracture fixation
Surgery to correct deformities
Bisphosphonates
T1 and T2 diabetes in pregnancy management
Pre-pregnancy counselling (good sugar control)
Folic acid 5mg
Consider change from tablets to insulin
Regular eye checks (due to accelerated retinopathy)
Use b-blocker, calcium channel blocker or methyldopa for blood pressure (avoid ACEI and statin)
Hypothyroidism in pregnancy management
Increase thyroxine by 25mcg as soon as pregnancy suspected
Check TFTs months for first 20 weeks then every 2 months
Aim for TSH <3
Investigation for hyperemesis gravidarum (to distinguish from hyperthyroid)
hCG (increased)
TSH (decreased)
TRab (negative)
Improves by 20 weeks gestation
Hyperthyroidism in pregnancy management
B-blockers if needed
Low dose anti-thyroid drugs (PTU 1st trimester, carbimazole 2/3rd)
Wait as late as possible before starting anti-thyroid drugs
Post-partum thyroiditis
Don’t treat in hyperthyroid stage
Do treat in hypothyroid stage
Thyroid nodule initial investigation and second line investigation
Thyroid function tests
US guided FNA
